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Dena
dena4301@att.net
828-429-4604
Forest City, NC 28043
Lead Clinical Consultant
31 years experience W2
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Summary

Experience
Lead Clinical Consultant
Medical Devices
Feb 2018 - present
WCRC Lead Clinical Consultant Senior Medical Consultant Subject Matter Expert Quality Assurance Expert Catastrophic Expert
  • Review and evaluate proposed Medicare set-aside arrangements, including submitted medical records, to determine if the proposed settlement meets the threshold requirements established for beneficiaries and potential beneficiaries and adequately considers Medicare's interests as pertaining to future medical service needs of beneficiaries
  • Facilitates training for new reviewers and acts as primary point of contact for complex clinical inquiries.
  • Audits complex recommendations to ensure compliance with organizational coding procedures and standards with specialization in catastrophic cases. Applies ICD, CPT, HCPCS, ASC and DRG coding as necessary.
  • Audit complex determinations for other clinical review programs utilizing medical records to ensure compliance with the organization's coding procedures and standards
  • Ensure all basic documentation requirements are available or requested via development action prior to review by medical and pharmacy review personnel
  • Render medical/clinical determinations based on professional experience
  • Implement operating rules and CMS policy
  • Processes legal consultations and conducts final attorney review on WCRC recommendations.
  • Provides QA for entire WCRC project
  • Developed Monthly "QA Corner" Newsletter
  • Developed Monthly Retro-Reviews
  • Performs Amended and Re-Reviews
  • Complex and Catastrophic Case Expert
  • Subject Matter Expert for Consults Franco Signor
No skills were added
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Medical Devices
Apr 2017 - Feb 2018
(Remote)
  • Developed Medicare Set Asides which included medical record review, chronologies, narrative, detailed future medical cost projections with pricing over lifetime, lifetime prescription medication for lifetime with pricing, calculated seed and annual to demonstrate annuity funding.
  • Review utilization management reports for accuracy and determine if proposed medical care is appropriate and within CMS guidelines.
  • Research appropriate guidelines regarding return to work and future medical care.
  • Assisted Claims Adjusters with Federal regulations and processes consistent with CMS guidelines. ExamWorks
No skills were added
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Online Adjunct Faculty
Jan 2014 - Jan 2016
  • Provided individual feedback/evaluations for students within the Bachelor's, Masters and Doctorate level classes in an online platform
  • Multiple different classes and programs
No skills were added
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Quality Control Specialist (Remote)
Medical Devices
Oct 2012 - Nov 2015
PMSI (now Optum United Healthcare
  • Led quality control activities for the organization in conjunction with project management to ensure accuracy and quality of all MSAs produced.
  • Led the quality assurance unit and coordinated with operations supervisors to assist in other business elements as needed.
  • Additional responsibilities included the preparation of MSA allocations and narratives. Live NCLEX-RN and LPN Review Classes
  • Conducted live 3-day review classes for both LPN and RN graduates in preparation for NCLEX as the sole instructor.
  • Developed teaching strategies and learning activities to keep students engaged and active in the review
  • Formulated individual study plans based on student participation in the review, which provided them with detailed information in areas of weakness and how to improve scores in those areas
  • Assisted students in developing critical thinking techniques and test-taking strategies
  • Covered Nursing Fundamentals, Adult Medical-Surgical, Mental Health, Maternal Newborn, Nursing Care of Children, Pharmacology, Nursing Leadership and Management as well as Community Health Nursing.
  • 98% pass rate of students who attended my reviews
  • Facilitated comprehensive training for new nursing graduates, to prepare them to take state boards.
No skills were added
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Surveyor/Evaluator
Medical Devices
Apr 2012 - Apr 2013
  • Traveled to colleges throughout United States to evaluate nursing, medical assisting, medical office administration and medical billing/coding to determine if the program/faculty/students achieved accreditation standards.
  • Provided recommendations regarding accreditation status in consideration of a university's findings in the categories of quality, ethical and educational experience.
No skills were added
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Program Director
Jun 2010 - Aug 2012
No skills were added
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Emergency Department RN
Medical Devices
Jan 2005 - Jan 2009
* Duties included, but not limited to, charge nurse duties, preceptor for new employees, SANE (Sexual Assault Nurse Examiner) Nurse, preparation/review of policies and procedures in preparation for Joint Commission and instructor for continuing education healthcare classes.
Nursing Registered Nurse
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Adjunct Faculty Member
Jan 2005 - Jan 2008
Foothills Nursing Consortium
  • Adjunct Faculty Member in Associates Degree RN program
  • Provided Classroom, Lab and Clinical Instruction in areas including Fundamentals of Nursing, Medical-Surgical Nursing, Mental Health Nursing, Pharmacology and Maternal-Child
  • Provided one-on-one tutoring in preparation for NCLEX
No skills were added
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Cruise Ship Medical Officer
Medical Devices
Jan 2005 - Jan 2008
Cruise Lines Cruise Ship Medical Officer
  • Part time contract work up to 4-weeks on board at a time
  • One of two Registered Nurse Medical Officers on board for the entire ship responsible for all medical care of 686 crew members and 1,410 passengers
  • Primary medical provider for all crew members on board for routine medical care of pre-existing conditions
  • Ran daily clinic for passenger medical problems and injuries
  • On call 24/7 for medical emergencies
  • Participated in all emergency drills: Medical emergency Fire Man Overboard Hostage Situations
  • In addition to routine nursing care, also responsible for all billing, radiology exams, dispensing of pharmaceutical medications and care of patients who required critical care admission to the infirmary
  • Responsible for determining situations in which medical evacuation/disembarkment was required and coordinated those efforts directly with the Captain as well as area Coast Guard or Fixed Wing Services.
  • Responsible for reporting of all cases of Norovirus to CDC daily to determine if we were sailing under green flag, orange flag or red flag.
  • Responsible for screening of all passengers in terminal prior to allowing them to embark
  • Responsible for determining need for quarantine for passengers who displayed certain symptoms
Nursing Registered Nurse
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Clinical Director/Office Manager
Jan 2000 - Jan 2005
  • Coordinated scheduling for 13 Cardiologists and approximately 30 RNs between two hospitals.
  • Refined practice SOPs, developed templates, established change control policies, and provided staff training on all office responsibilities within scope.
  • Responsible for maintaining office supplies and ensuring equipment was both functional and in compliance with maintenance requirements.
  • Assisted with office patients, stress tests, on call and in cardiac catheterization lab as needed.
  • Conducted routine staff meetings to ensure staff compliance with hospital regulations and standard processes.
  • Managed practice payroll and staffing schedule for all clinical personnel.
Compliance
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Emergency Department RN
Medical Devices
Jan 1998 - Jan 2000
  • Level-One Trauma Center RN
  • Applied strong decision-making skills to access emergency scenarios and ensured appropriate care ensued as a result.
  • Treated critical injuries, allergic reactions and trauma in coordination with peers ensuring emergency room care standards were maintained.
  • Ensured the efficiency of the patient check-in process and assisted with insurance paperwork.
  • Charge nurse and preceptor.
Nursing Registered Nurse Trauma Center
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Surgical RN
Medical Devices
Jan 1996 - Jan 1998
  • Provided pre and post-op patient support to include preparation of incision sites, bandaging and stitching up wounds and incisions, transportation of the patient to the recovery room and monitoring of patient until the patient is transferred to another unit.
  • Charge nurse and preceptor.
  • Met with patients and their families prior to surgery and explained procedures and expected recovery time.
  • Prepared the operating room and assisted other members of the surgical team in their preparation.
  • Acted as preceptor for new unit resources. Also assisted as a CPR and ACLS Instructor.
ACLS CPR Certified Nursing Operating Room Post-op Registered Nurse Surgical Nursing
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RN
Medical Devices
Jan 1990 - Jan 1996
Mary Black Memorial
  • Met with expectant mothers for prenatal visits and provided care for normal and problematic pregnancies.
  • Charge nurse and preceptor.
  • Provided information, guidance, and hands-on clinical care to pregnant women.
  • Monitored fetal heartbeat and length and strength of contractions during labor.
  • Coached women, assisting with any complications, and administering medications during birth.
  • Provided guidance to new mothers on all aspects of recovery and infant care.
  • Used equipment and administered medications related to labor, delivery, and the care of newborns.
Nursing Registered Nurse
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Edit Skills
Non-cloudteam Skill
Education
Health Care Administration
American Continental University 2011
Health Care Law
Concord Law School 2007
Nursing
University of Phoenix 2003
Nursing
Gardner Webb University 1991
Certifications
Medicare Set Aside Certified Consultant Certification #1094
Legal Nurse Consultant Certified Certification #17720991
Certified Life Care Planner Certification #1384
Certified Workers' Compensation Professional
Certificate in Nursing Education through Western Carolina University
Nursing License Number Compact State: North
Carolina - 148993
Skills
Nursing
2009
17
Registered Nurse
2009
17
Compliance
2005
5
ACLS
1998
2
CPR Certified
1998
2
Operating Room
1998
2
Post-op
1998
2
Surgical Nursing
1998
2
Trauma Center
2000
2